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July 5, 2016

The Painful Opioid Epidemic

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As the nation’s opioid abuse epidemic continues to make headlines and eat away at the very soul of rural communities, Washington, D.C. continues to weigh how much funding to combat it will be appropriated and where.

The concern regarding Congress is twofold:

1. Will it appropriate enough money to robustly address all the needs? 2. Will it include funding for treatment and prevention programs?

Congressional Democrats are seeking $600 million, the President has asked for $1.1 billion, and Republican leaders playing it close to the vest have not clearly stated how much they would be willing to spend, but some seem to suggest that the total should be offset by reductions in other programs or increases in revenue. So while that dance is in motion, the White House just recently announced the estimated amount of funding each state could quality for under cooperative agreements proposed in President Obama’s budget to address opioid treatment – and more specifically, medication-assisted treatment.

To that end:

States would receive funding based on the severity of the epidemic in their respective communities.

Increasing substance use disorder treatment services, with a specific focus on expanding medication-assisted treatment of opioid use disorders in underserved communities.

Ensuring that nursing and pharmacy schools commit to training for their students as it relates to guidelines for prescribing opioids for chronic pain.

Expanding the federal prescription drug overdose program to support prevention efforts in 29 states.

Expanding local partnerships between law enforcement and their counterparts in public health to combat heroin use and overdoses, including initiatives in high-level drug trafficking areas like Appalachia, New England, Ohio and Michigan, New York and New Jersey, Washington/Baltimore, and Philadelphia/Camden.

Continuing National Prescription Drug Take-Back Day, which offers a safe, convenient, and responsible way of disposing of unneeded prescription drugs. From this, not only have millions of pounds of medication been collected, but local communities are also establishing ongoing drug takeback programs.

Finger-Pointing Versus Pointing in the Right Direction

So while we wait for legislation and funding, interspersed with solutions is the “blame game” emerging in the nation’s media headlines. Being blamed are:

First, physicians, who have been viewed as the smoking gun (others might say the scapegoat) for the epidemic for allegedly prescribing too many painkillers versus other methods of treatment.

The federal government, which allegedly hasn’t been proactive enough to recognize that this epidemic has been in the making for years.

Lack of national and statewide plans unifying public health and healthcare for communities and individuals, recognizing that they go hand in hand.

Lack of appropriated money in behavioral health services to get to the root of some of the addictions.

Lack of an agenda focusing on personalized care, targeting what the individual needs versus general medication treatment.

Lack of cooperation from payor groups, which traditionally have offered a limited scope of coverage offerings, centering more on prescription meds versus holistic/alternative approaches.

Waiting for Money – Accountability and Activity

Capitol Hill and the White House aren’t the only places where such discussions are taking place – conferences, membership organizations, and associations all are listing the epidemic as a central priority on agendas, in webinars, and across social media platforms, focusing on shifting “accountability to activity” while noting that “silos limit success.” From the National Rural Health Association (NRHA) to the American Hospital Association (AHA), the numbers of proposed strategies are growing.

NRHA leadership has its finger on the pulse of meetings being held in D.C. and among the Association’s rural membership, including hospitals, clinics, and providers that are actively engaged in developing and sharing ideas and initiatives. The AHA recently called for a series of next steps that would ease physicians' prescriptions of opioids and emphasize alternatives and creating support tools for preventing overdoses.

Taking a closer look at the AHA (which has many rural members) and its House of Delegates:

The group chose to oppose any barriers that could limit patient access to evidence-based, non-opioid and non-pharmacological pain therapies.

The group cited support for easing physicians' prescriptions of alternatives to opioids and support tools for preventing overdose.

The group also voted in favor of efforts to remove pain as a vital sign in professional standards, as well as disconnecting patient satisfaction scores from questions related to the evaluation and management of pain.

The delegates Wednesday also adopted new policies promoting greater access to naloxone, a drug that can counter the effects of drug overdose.

Also, let’s not forget two other voices: the Centers for Disease Control and Prevention (CDC) recently recommended that doctors prescribe alternative treatments such as over-the-counter medications, cognitive behavioral therapy, and exercise before resorting to opioids. Additionally, the Joint Commission clarified its 2001 standards for pain management and treatment to stress, noting that opioid use was neither required nor specified for treating pain.

Beyond a structured agenda, one thing is for sure: the opioid epidemic is now a leading cause of death in the United States, claiming more than 47,000 lives in 2014 as a result of a drug overdose, according to the CDC. More than 18,000 of those incidents involved the use of prescription pain relievers, and the crisis is leading to complicated conversations with patients regarding treatment options, often revealing deeper needs and issues of physiological or emotional problems that aren't easily resolved and require long-term treatment.

Alternatives and Options

Medical marijuana has increased in use across several areas of the nation and is approved in 38 states and the District of Columbia for patients with illnesses such as cancer and HIV, but only a handful of those states allow the use of marijuana to relieve chronic pain.

There are several other alternative strategies, including psychological counseling, physical therapy, chiropractic care, precision-focused exercise, anti-inflammatory /neuropathic medications, changes in diet, and vitamin supplements – any of which could be provided as options for care and pain management.

Currently, a Food and Drug Administration (FDA) advisory panel is considering a mandate for all physicians to complete additional training to prescribe these medications. Many states already require doctors to complete continuing medical education on the topic. Doctors who specialize in pain medicine are already well-versed in the area.

However, adding more layers of training would tie up resources. People who need these medications would have nowhere to turn until training had been completed by their physician, or otherwise they would need to change doctors in order to obtain them. Patients with cancer and chronic pain would be left to suffer in the meantime. Is this really the direction we want to go?

Another approach is the creation of “opioid abuse committees” that are used to identify best practices, address vulnerable patient populations by managing prescriptions, and make sure patients understand what their medications are supposed to do, providing clear directions on how to use and properly store them. This works well for urban populations, but rural markets lack the bandwidth for additional specialized committee structures.

Opioid centers are also cropping up in many states, with many located in the South, and while there has been some coverage of how this is an option, drugs dispensed to fight the opioid abuse are in fact drugs themselves: methadone. Critics say the result is merely exchanging one drug abuse for another addiction. This is counterproductive for rural populations, for which there is also often workforce issues to address.

Adding to the stress within rural markets is that there are barriers to access and delivery of care for alternative therapies and a lack of training and information for some primary care physicians about how to provide a multi-disciplinary approach to pain management. The result is that it is easier for a prescriber to stay the course of traditional reaction – and to merely write a script.

Federal Government Options There is an abundance of opportunities through which the federal government could make some progress addressing the opioid epidemic; however, not all are applicable for rural populations due to access issues, service barriers, and workforce challenges.

Although it’s obviously not capable of ending all overdoses, the federal government could remove barriers to the access of the opioid bupernorphine, which has proven effective at weaning people off stronger drugs like heroin. This however, wouldn’t necessarily work in the rural markets because of their limited number of physicians, the need for at least eight hours of training, and the patient limits currently required in treating patients with the drug.

High-quality treatment programs could be expanded.

Federal and state officials need to pressure insurance plans to cover substance abuse treatment, just as Medicaid and plans sold on health insurance exchanges are mandated.

Capacity building for agencies to oversee and implement more grants and program initiatives needs to be accomplished.

Options at the State Level

States should work directly with healthcare systems, state health improvement plans, public health departments, physicians and healthcare associations, and urgent care centers to develop opioid committee structures to meet patient needs and limit opioid prescriptions.

States need to leverage policies or pass legislation such as that has been passed in New Hampshire and Massachusetts to reduce the prescribing of opioids.

Insurers must be required to cover alternative pain treatment services.

No root cause analysis studies indicating why people are turning to drugs and what underlying causes exist, such as depression or anxiety.

Possible Physician Solutions for Rural and Urban Areas

Doctors staging interventions;

Speaking at town hall meetings;

Developing lecture series; and

Training peers in pharmacogenetics for advanced diagnostics for metabolic processing and genetic predispositions.

One important recent online education commitment to address opioid use and abuse came from the CDC via a seven-part webinar series (each portion being one hour) about the “guidelines for prescribing opioids for chronic pain.” Future modules will focus on various recommendations in the guidelines. These are free and provide CEUs to physicians, nurses, pharmacists, health educators, and other healthcare providers.

It’s just the beginning

America needs detox – and the advancements have to be made with payers playing an integral role. When Prince died in April, it only advanced the headlines and national talk, but we need to advance the dialogue from a detox wake-up call to policy, proactive precision, and payer partnerships. It is often said that the health of a nation is only as robust as the nation itself, and public health epidemics poke permanent holes in this. Let’s hope that Congress and the White House are in sync with funding, purpose, and committed programmatic sustainability.

Silos won’t work, and payers, physicians, healthcare organizations, public health departments, advanced diagnostic labs, urgent care centers, and associations need to work cohesively to develop the best game plan for the health and sustainability of our nation to eradicate such epidemics and champion the best in equity and access as possible. If not, the rural treasures of this nation will be left behind.

Yes, Prince’s death spoke with equal impact as his music – it exposed a hidden vulnerability in all of us and the nation.

The only problem is – it’s not 1999 anymore.

About the Author

Janelle Ali-Dinar, PhD is a rural healthcare expert and advocate with more than 15 years of healthcare executive experience in many key areas, addressing critical access hospitals (CAHs), rural health clinics (RHCs), physicians, and patients. Dr. Ali-Dinar is also a sought-after speaker on Capitol Hill.

A former hospital CEO and regional rural strategy executive, Janelle is a past National Rural Health Association rural fellow, Rural Congress member, and Nebraska Rural Health Association president. She is currently the Nebraska DHHS Chair of The Office of Minority Health Statewide Council, addressing needs of rural, public, minority, tribal, and refugee health, and serves on the Regional Health Equity Region VII council as co-chair of rural health and partnerships. Janelle holds a master’s degree and doctorate in communications and is a recent graduate in public health leadership. Janelle is currently the vice president of rural health for MyGenetx.